Basic Information
| Provider Information | |||||||||
| NPI: | 1205082211 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KENNALEY | ||||||||
| FirstName: | ROSEMARIE | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4600 S MILL AVE | ||||||||
| Address2: | STE 280 | ||||||||
| City: | TEMPE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852826850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4803052888 | ||||||||
| FaxNumber: | 4803052889 | ||||||||
| Practice Location | |||||||||
| Address1: | 428 S GILBERT RD | ||||||||
| Address2: | STE 101 | ||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852962261 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4806778282 | ||||||||
| FaxNumber: | 4806778283 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2008 | ||||||||
| LastUpdateDate: | 02/11/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 23812 | AZ | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 357526 | 05 | AZ | MEDICAID |